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The Scope of Infant Mental Health

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 CHAPTER 1
The Scope of Infant Mental Health
Charles H. Zeanah, Jr.
Paula Doyle Zeanah
nfant mental health has emerged as an in-
Iendeavor
creasingly important and visible clinical
during the past 35 years. There are
many ways to trace its origins. In the clini-
cal realm the work of Selma. Fraiberg and
her colleagues in Michigan (Fraiberg, Adel-
man, & Shapiro, 1975) was a major early
contributor, as was research in developmen-
tal psychology on the power of babies to af-
fect their caregivers (Bell, 1968). From these
beginnings, the field of infant mental health
has grown dramatically both in terms of its
breadth and its acceptance. In the early 21st
century, the field of infant mental health
stands as .a broad-based, multidisciplinary,
and international effort to enhance the social
and emotional well-being of young children
and which includes the efforts of clinicians,
researchers, and policymakers.
Still, as a relatively new field, a number
of questions ought to be considered. For ex-
ample, how is infant mental health defined?
Some have expressed puzzlement or even
aversion to the term "infant mental health."
The idea of an "infant," with its associations
of innocence, beginnings, and hope for a bet-
ter future, does not seem to fit with "mental
health," and its associations of maladjust-
5
ment, stigma, and major mental illness. Is it
reasonable to think of infants as having men-
tal health problems? Or does it make more
sense to think about them as being at tisk
for problems later? There are also questions
about "infant mental health" as a profes-
sion. In a multidisciplinary field how is core
knowledge versus specialized knowledge
determined? Are infant mental health inter-
ventions qualitatively different from mental
health" interventions for older children and
adolescents? Finally, how is infant mental
health similar to, and distinct from, other
closely related multidisciplinary fields, such
as developmental psychopathology?
We begin by defining infant mental health
and considering its scope. We suggest that
die relational framework of infant mental
health distinguishes it from work with older
children and adolescents. We review some of
the major empirical foundations of the field,
highlighting the implications of these foun-
dations for an infant mental health perspec-
tive. Finally, we emphasize the need for com-
prehensive approaches· to intervention and
highlight some evidenced-based programs.
Throughout, we emphasize the policy impli-
cations of this work.
6 I. DEVELOPMENT AND CONTEXT
DEFINING INFANT
MENTAL HEALTH
A Steering Committee on Infant Mental
Health was convened by Zero to Three and
tasked with creating a definition of infant
mental health. What emerged was a defini-
tion of infant mental health as a characteris-
tic of the child. That is:
the young child's capacity to experience, regu-
late, and express emotions, form close and
secure relationships, and explore the environ-
ment and learn. All of these capacities will be
best accomplished within the context of the
caregiving environment that includes fam-
ily, community, and cultural expectations for
young children. Developing these capacities is
synonymous with healthy social and emotion-
al development. (Zero to Three, 2001)
This definition seems to have met with
widespread acceptance by the field (Zeanah,
Gleason, & Zeanah, 2008).
In addition, infant mental health can be
defined as a multidisciplinary professional
field of inquiry, practice, and policy, con-
cerned with alleviating suffering and enhanc-
ing the social and emotional competence of
young children. Infant mental health is mul-
tidisciplinary because the complex, interre-
lated nature of human development and its
deviations requires expertise and conceptu-
alizations beyond the capabilities of any par-
ticular discipline. For the same reason, it is
likely that the field of infant mental health
will remain pluralistic, a subspecialty within
a number of different disciplines, rather than
an integrated and distinct discipline itself.
A definition is also needed for what we
mean by the term "infant." In pediatrics, in-
fant usually refers to the first year of life. In
mental health, there is a tradition that infant
refers more broadly to the period from birth
to 3 years. In this chapter, however, we use
an even broader conceptualization. First,
as famously declared in From Neurons to
Neighborhoods (National Research Coun-
cil and Institute of Medicine, 2000), focus-
ing disproportionately on birth to 3 years
"begins too late and ends too soon" (p. 7).
Because there is considerable evidence re-
garding prenatal influences on many clinical
problems in early childhood (see Robinson
et al., 2008), we include prenatal experience
in our conceptualization of infant mental
health. We also extend the upper age limit
from 3 to 5 or so years, because much re-
search and many clinical programs extend
somewhat beyond the first 3 years.
Beyond these definitions, several tenets re-
garding the clinical practice of infant mental
health merit attention. These include a focus
on strengths in infants and families, a rela-
tional framework for assessment and inter-
vention, and a prevention orientation.
Infant mental health is a strengths-based
discipline. This means that clinicians work to
identify strengths from which to build com-
petence and address problems. One could
rightly argue that all mental health profes-
sionals ought to work from a strengths-
based perspective, but it seems especially im-
portant in a field that focuses on the crucial
and vulnerable beginnings of parent-child
relationships. Our children are extensions of
ourselves, and when they do not thrive, we
experience it as a reflecting profoundly on
us as parents. Nevertheless, being strengths-
based does not mean ignoring liabilities
(Zeanah, 1998). Clinicians must identify
problems in young children and in their par-
ents unflinchingly in order to address them
effectively. Further, there is often a complex
interrelationship between strengths and
weaknesses, such that strengths may be ob-
scured by weaknesses but also possibly mo-
bilized to ameliorate weaknesses.
Infant-caregiver relationships are the pri-
mary focus of assessment and intervention
efforts in infant mental health, not only be-
cause infants are so dependent upon their
caregiving contexts but also because infant
competence may vary widely in different re-
lationships. Assessments in infancy always
are considered a form of intervention, as
they may have important impacts on both
infant and family. Moreover, intervention
efforts always involve prevention, because
the infant is considered as constantly devel-
oping, and the infant's developmental trajec-
tory must be attended to in addition to here-
and-now adaptation. This means that there
is a simultaneous focus on relieving current
suffering as well as attending to future de-
velopment, all through attention to primary
caregiving relationships (Zeanah, Stafford,
Nagle, & Rice, 2005; Zeanah, Stafford, &
Zeanah, 2005; Zeanah & Zeanah, 2001).
Just as young infants engender hope for a
better future in general, the field of infant
 1. The Scope oflnfant Mental Health
mental health strives to delineate, establish,
and sustain positive developmental trajec-
tories for young children. In all of these ef-
forts, the empirical foundations of infant
mental health have broadened and deepened
in ways that have important implications for
practice and policies.
EMPIRICAL FOUNDATIONS
OF INFANT MENTAL HEALTH
Basic knowledge salient to infant mental
health has been bolstered by research in
genetics, basic neuroscience, child develop-
ment, developmental psychopathology, and
by studies of clinical disorders and their
treatment. Investigations in these areas
provide the empirical foundations of infant
mental health.
Early Experiences Matter
Considerable research has documented the
importance of early experiences for the de-
veloping person. Brain circuits are being es-
tablished at an extremely rapid rate in the
early years of life, and various experiences
influence not only how brains function but
also the neural architecture of how they de-
velop. We are only just beginning to attempt
to understand the details about how expe-
riences influence brain development, but
evidence in humans on this point is grow-
ing (see Sheridan & Nelson, Chapter 3, this
volume).
Although mild to moderate stress can be
growth promoting, so-called toxic stress
can impair the proper development of brain
circuitry, which may be especially vulner-
able during early childhood (Middlebrooks
& Audage, 2008). If individuals develop a
lower threshold for stress, thereby becom-
ing overly reactive to adverse experiences
throughout life, both physical and mental
health can be compromised (see also Rifkin-
Graboi, Borelli, & Bosquet Enlow, Chapter
4, this volume). For example, in the adverse
childhood experiences (ACE) study, adults
receiving treatment from a health main-
tenance organization (HMO) were inter-
viewed about early childhood experiences of
abuse, neglect and household dysfunction.
The number of childhood risk factors was
linearly related to a large number of health
7
and mental health outcomes. The more ad-
verse experiences individuals reported hav-
ing, the more likely they were to engage in
risky health behaviors and to be diagnosed
with disorders such as depression, alcohol-
ism and substance abuse, heart disease, can-
cer, chronic pulmonary disease, obesity, and
diabetes, among others (Dube, Felitti, Dong,
Giles, & Anda, 2003; Feletti et al., 1998).
These findings remind us that infant mental
health has important implications for health
as well as mental health outcomes.
A related question concerns the ways in
which the timing of experiences matter, usu-
ally framed as a "sensitive period" or "criti-
cal period" hypothesis. Knudsen (2004)
notes that the period during which the ef-
fects of experience on the brain are par-
ticularly strong is referred to as a sensitive
period, whereas experiences that provide in-
formation that is crucial for normal develop-
ment and alter performance permanently are
known as critical periods. Animal literature
reveals that sensitive and critical periods in
brain development are evident (Knudsen,
2004).
Knudsen (2004) also notes that sensitive
and critical periods are actually properties
of neural circuits, though we may be most
interested in how the effects of these vari-
ous periods are expressed at the level of be-
havior. For example, Nelson et al. (2007)
studied children removed from institutional
care in the first 3 years of life and placed
in foster families and reported increases in
IQ. For children removed prior to 24 months
the gains were substantial, but for those re-
moved after 24 months, the gains were few.
For a construct as complex as IQ, we would
expect to find an enormous number of cir-
cuits with different sensitive or critical peri-
ods involved.
In keeping with these findings, infant
mental health has the importance of infant
experience as a core principle. Escalona
(1967) anticipated this emphasis almost
half a century ago when she noted that it is
not infant or environmental characteristics
that matter so much; rather it is the infant's
subjective experience of the world. Indeed,
developmental psychopathology has demon-
strated that stabler individual differences lie
initially in the infant-caregiver relationship,
only later becoming a characteristic of the
individual child. Further, how an individual
8 I. DEVELOPMENT AND CONTEXT
thinks about relationship experiences-the
internal representation or working model-
is crucial because the meanings an individ-
ual attributes to experiences may alter their
consequences (Sroufe, 1989; Sroufe & Rut-
ter, 2000).
For the infant mental health clinician, the
task becomes nothing less than attempting
to understand what an individual child's ex-
perience is and to help that child's caregiv-
ers empathically appreciate that experience.
From a policy perspective, even more daunt-
ing is the challenge of attempting to extend
this appreciation of an infant's experience to
the level of systems, such as the child protec-
tion system or the legal system. How differ-
ent the lives of infants in dire circumstances
might be if these large and complex systems
better appreciated and valued their experi-
ences (Knitzer, 2000).
Essential Experiences Involve
Caregiving Relationships
The importance of the contexts, or environ-
ments, in which infants grow and develop is
well established. Appreciating the complexi-
ties and importance of context has enhanced
our understanding of infant development
and our ability to predict developmental
trajectories (Sameroff & Fiese, 2000). Con-
texts exert their effects from within and
from without, determining which experi-
ences an infant has and how that infant per-
ceives those experiences. One of the most
distinctive features of the early years is the
clear importance of the multiple interrelat-
ed contexts (infant-caregiver relationship,
family, cultural, and so forth) within which
infants develop. For young children, infant-
caregiver relationships are the most impor-
tant experience-near context for infant de-
velopment and are the distinctive focus of
the infant mental health field.
A considerable body of research has docu-
mented the importance of the quality of the
infant-caregiver relationship and its impact
on infant development (National Research
Council and Institute of Medicine, 2000). In
fact, although individual differences in infant
characteristics are readily identifiable, they
are not particularly predictive of subsequent
characteristics later in development. Posi-
tive qualities in infant-parent relationships,
such as warmth, attentive involvement, and
sensitive resolution of distress, have been
linked to more optimal social, emotional,
and cognitive development (see Crockenberg
& Leerkes, 2000). In addition, parents who
promote the development of self-regulation
and minimize problematic behavioral ten-
dencies have children who avoid maladap-
tive trajectories (Degnan, Henderson, Fox,
& Rubin, 2008; Gardner, Sonuga-Barke, &
Sayal, 1999). Conversely, parents who have
problematic relationships with their young
children may increase the likelihood of mal-
adaptive outcomes in them (Scheeringa &
Zeanah, 2001).
Infant-parent relationships moderate in-
trinsic biological risk factors in infants (Mc-
Carton et al., 1997). That is, infants with
biological difficulties, such as the complica-
tions of prematurity or adverse temperamen-
tal dispositions, have better outcomes when
their caregiving environments are support-
ive, and they have more problematic out-
comes when their caregiving environments
are less supportive. Further, attachment re-
lationships moderate the effects of prenatal
stress on child fearfulness at 17 months, even
after controlling for the effects of postnatal
stress, as well as obstetric, social, and demo-
graphic factors (Bergman, Sarkar, Glover, &
O'Connor, 2008).
Infant-parent relationships also are the
conduit through which infants experience
environmental risk factors (Zeanah, Boris,
& Scheeringa, 1997). That is, infants expe-
rience risk factors such as poverty, maternal
mental illness, and partner violence primar-
ily through the effects of those factors on
infant-parent relationships. Infants are im-
pacted by the risk factors that characterize
their caregiving environments through their
specific relationship experiences. The bot-
tom line: Relationships can buffer or exac-
erbate risk.
Finally, increasingly we are learning that
the way in which psychopathology is ex-
pressed in young children depends on the
types of relationships they have with their
caregivers (Zeanah et al., 1997). Research
has shown that infants, in fact, construct
different types of relationships with different
caregivers (Steele, Steele, & Fonagy, 1996),
and they also may express symptoms in the
presence of once caregiver but not with an-
other (Zeanah, Bakshi, Boris, & Lieberman,
2000). And, there is evidence that how an
 1. The Scope oflnfant Mental Health
individual processes relationship experi-
ences, through an internal working model,
is importantly related to outcomes (Sroufe,
1997).
for all of the above reasons, the focus of
infant mental health has been dominated
by a relational approach. This means that
infants are best understood, assessed, and
treated in the context of their primary care-
giving relationships. Or as Sroufe (1989) put
it, "Most problems in the early years, while
often manifest poignantly in child behavior,
are best conceptualized as relationship prob-
lems" (p. 70).
Beyond the infant-caregiver dyad, we
must consider infant development in the
context of the entire family. Not only is
infant development related to character-
istics of the family considered as a whole
(Minuchin, 1988), but there are important
effects on development from the infants in-
dividualized relationships with various fam-
ily members (Crockenberg, Lyons-Ruth, &
Dickstein, 1993; Favez, Frascorola, Keren,
& Fivaz-Depeursinge, Chapter 29, this vol-
ume). For example, considerable evidence
indicates that the parents' marital relation-
ship is one of the most important influences
on child development (Cummings & Davies,
2002). Sibling influences on infant develop-
ment are less well studied, but they are likely
vitally important. Understanding family
processes is a complex undertaking. Emde
(1991) has pointed out, for example, that
the numbers of dyadic relationships within
families increases dramatically with increas-
ing numbers of children. Whereas two par-
ents and one child have only three dyadic
relationships to consider, two parents and
three children have 10 dyadic relationships,
and two parents and five children have 21
dyadic relationships, and so forth. Further,
an infant's relationships with various family
members are influenced by various other re-
lationships within the family. The numbers
of dyadic relationships influencing individu-
al family members increase from 3 for two
parents and one child, to 4 5 for two parents
and three children, to 210 for two parents
and five children (Emde, 1991). Obviously,
one could also consider other levels of com-
plexities, such as how an infant and his or
her relationships might be affected by the
triadic relationship of his or her parents and
another sibling. Nevertheless, these levels of
9
complexity are rarely considered in research
or even in our clinical conceptualizations.
Beyond the immediate family of the infant,
still other familial influences are important,
chief among which are the cultural contexts
within which infants develop. Cultural be-
liefs and value systems define the assump-
tions of the group about what is important
and the rules about raising children to be a
certain way. Parenting beliefs, explanations,
and interpretations of infant behavior are
among the most important components of
the cultural context of infant development
(Lewis, 2000). These beliefs include some-
times subtle cultural assumptions about
what facilitates infant development, the
causes and amelioration of psychopathol-
ogy, the roles and relevance of parenting,
and many other concerns central to infant
mental health. Cultures typically develop
adaptively in response to larger environ-
mental characteristics, such as the physical
resources of the area in which the culture de-
velops. Often differences among cultural be-
lief systems can be understood within those
larger contexts. In recent decades, however,
technological advances have thrust different
cultures together with increasing rapidity
and led to intense cultural clashes, efforts at
cultural coexistence, and pressures for cul-
tural integration in the global village. All of
these factors have significant implications
for infant development and mental health.
The policy implications of these findings
are clear and can be simply stated: Policies
aimed at supporting families and other care-
giving relationships, such as child care, are
most likely to provide needed supports for
infant development (Center on the Develop-
ing Child at Harvard University, 2007).
Supporting Developmental Trajectories
The rapidity and profundity of development
in the first 3 years of life is unprecedented in
the postnatal human life cycle. In a mere 36
months, infants change from totally depen-
dent newborns to complex creatures who can
come and go as they please; understand that
they can share thoughts, feelings, and inten-
tions with others; express themselves ab-
stractly using symbols; and empathize with
others (Zeanah & Zeanah, 2001). From an
infant mental health perspective, this devel-
opmental continuum means not only think-
10 I. DEVELOPMENT AND CONTEXT
ing about where the infant is now but also
where the infant has been and where the
infant is going. It also requires understand-
ing not only what capacities are emerging in
the developing child but also the processes
involved in establishing trajectories of devel-
opment.
Risk and Protective Factors
Risk and protective factors impact develop-
mental trajectories, increasing or decreasing
the risks of developmental disruptions and
psychopathology. These risk factors are used
to define high-risk groups, such as infants
born preterm, infants of depressed mothers,
and infants raised in institutions. On the
other hand, risk factors are neither random-
ly distributed nor unrelated to one another.
Complexly interacting risk factors within
groups are the rule rather than the excep-
tion. In other words, although intervention
programs may target single risk factors, such
as substance abuse, maternal depression, or
early parenthood, most of the time, infants
face multiple risk factors.
Studies of many types of risk factors, from
mild to severe, consistently have been shown
to lead to quite variable outcomes (Sroufe
& Rutter, 2000). In fact, it appears that the
number of risk factors rather than the nature
of any one is the best predictor of outcomes
(Sameroff & Fiese, 2000). For example, pre-
natal substance exposure is widely accepted
to be a risk factor for infant development
(Boris, Chapter 10, this volume). Neverthe-
less, Carta et al. (2001) studied the effects
of prenatal exposure and environmental
cumulative risks. They found that although
both prenatal drug exposure and cumulative
environmental risk predicted children's de-
velopmental level and rate of growth, envi-
ronmental risk accounted for more variance
in developmental trajectories than prenatal
drug exposure. In fact, over time, the ef-
fects of environmental risk outweighed the
adverse consequences of prenatal substance
exposure.
Protective factors may directly reduce the
effects of risk, may enhance competence, or
may protect the individual against adver-
sity (Garmezy, Masten, & Tellegen, 1984).
Protective processes may operate simultane-
ously or successively even within the same
individual in the face of different challenges
and at different points in development.
As noted, the field of infant mental
health has a long tradition of focusing on
strengths and using strengths to minimize
risks (Knitzer, 2000; Zeanah, 1998). A cen-
tral concern then, for, infant mental health
is how to balance the influence of risk and
protective factors and their mutual effects
on a child's particular situation. In addition,
in the first few years of life, it appears that
environmental risk and protective factors
matter more than within-the-infant risk and
protective factors. In the Rochester longi-
tudinal study, for example, highly compe-
tent infants in high-risk environments fared
worse in terms of competence at age 4 years
than did low-competent infants in low-risk
environments (Sameroff, Bartko, Baldwin,
Baldwin, & Seifer, 1998). Thus, identifying,
supporting, and strengthening caregiver and
family strengths is a fundamental principle
underlying the work of infant mental health
practitioners and provides direction for poli-
cymakers interested in supporting young
children.
Psychopathology May Be Evident Early
Can infants and toddlers experience or ex-
press psychopathology? The existence of psy-
chopathology in infancy has been the source
of considerable controversy in part because
we are reluctant to believe that infants can
experience or suffer from psychiatric disor-
ders (Zeanah et al., 1997). Behavioral indi-
cators of infant mental health include emo-
tion regulation, the ability to communicate
feelings to caregivers, and active exploration
of the environment. These behaviors lay the
groundwork for later social and emotional
competence, readiness to enter school, and
better academic and social performance.
One major approach to studying psycho-
pathology in the early years is a multidisci-
plinary endeavor known as developmental
psychopathology. It concerns identifying de-
velopmental trajectories and those risk and
protective factors and processes that increase
or decrease the probability of positive devel-
opmental outcomes. Clinical disorders may
be less than fully differentiated in infancy
(but see Angold & Egger, 2007, regarding
preschool children). Developmental psycho-
pathology emphasizes identification of in-
dividuals with developmental delays (devel-
opment is behind where it ought to be, but
the child is otherwise normal) or deviance
 1. The Scope of Infant Mental Health
(development is abnormal) even before an
actual disorder has emerged. Thus, preven-
tive interventions, targeted to children with
risk factors but not yet manifesting a disor-
der, can be developed. Finally, because there
is interest in the process of how disorders
develop, the field of developmental psycho-
pathology studies the ~volution o~ ~isor?ers
over time rather than simply exammmg signs
and symptoms at a single point in time.
Psychopathology often is characterized
by the inability to change and adapt, but
infants are constantly changing by develop-
ing. This means that infant problems must
be distinguished from the often large range
of normal variations in behavior and from
transient perturbations in development. Ob-
viously, one way to address this challenge is
to follow children over time and determine
whether problems persist. On the other
hand, it is important to recognize that psy-
chopathology and maladaptation may not
produce static symptomatology; rather, the
manifestations of problems may be different
at different times in development. For exam-
ple, indiscriminate behavior toward unfa-
miliar adults in early childhood is a predic-
tor of serious peer relational disturbances in
adolescence (Hodges & Tizard, 1989)-the
continuity is in interpersonal disturbances,
but they manifest differently at different
ages. Lawful developmental transformation
of symptomatology, known as heterotypic
continuity, adds to the complexity of assess-
ing psychopathology in infancy and early
childhood.
For an individual child, however, risk
factors are less important than the actual
development and functioning of that indi-
vidual child at a given time. Clinicians must
determine whether a given child, at a given
moment, has sufficient distress or maladap-
tive behavior to constitute a disorder that
requires intervention. This area introduces
the other approach to psychopathology in
infancy, which is to consider that at least
some infant problem behaviors are signs and
symptoms of psychiatric disorders. Clini-
cians have found the use of categorical di-
agnostic approaches to be valuable in young
children, as they allow for conceptualizing
how clusters of symptoms hang together and
provide clearer indicators of "caseness" than
do dimensional scores of various constructs.
Though some still hesitate to describe
early deviant behavior as psychopathology,
11
rather than risk for psychopathology, there
are increasingly compelling reasons to think
that doing so is a useful approach. For ex-
ample, most would agree that autism repre-
sents a disorder, and there are compelling in-
dicators that autism as a disorder is evident
at least as early as the second year of life
(see Carr & Lord, Chapter 18, this volume).
There are almost certainly neurobiological
abnormalities and behavioral differences
that are evident even before the second year,
but the reliability of a categorical diagnosis
of autism from about 2 years of age is rea-
sonable.
New studies are beginning to show that
many types of psychiatric disorders are
prevalent in young children. A recent study
of more than 300 two- to five-year-old chil-
dren attending pediatric clinics in Durham,
North Carolina found that 16% had diag-
nosable psychiatric disorders associated
with impairment in functioning (Egger et
al., 2006). This prevalence rate in nonre-
ferred preschool children is almost identical
to the 13 % rate reported in older children
and adolescents (Costello, Mustillo, Erkanli,
Keeler, & Arnold, 2003 ).
There also has been progress in distin-
guishing transient individual differences
from true psychopathology. Belden, Thom-
son, and Luby (2008) studied temper tan-
trums in healthy versus depressed and
disruptive preschoolers. They found that
preschoolers diagnosed with disruptive be-
havior disorders had more tantrums, more
lasting tantrums, and more violent tantrums
than other children. Preschoolers diagnosed
with depression, in contrast, displayed more
self-harm during tantrums than their healthy
or disruptive peers. The conclusion is that
children having more violent tantrums and
tantrums associated with self harm require
more careful monitoring and perhaps refer-
ral for assessment. In addition, separation
anxiety as a disorder can be differentiated
from more transient separation anxiety in
2-year-old children by the degree of impair-
ment (Egger, 2008).
Despite all of these findings, there has
been widespread dissatisfaction among cli-
nicians about using DSM-IV-TR (American
Psychiatric Association, 2000) criteria to
diagnose disorders in young children. New
diagnostic classifications systems have been
created to provide more developmentally
appropriate criteria, and also to provide a
12 I. DEVELOPMENT AND CONTEXT
basis for studying the construct validity of
diagnoses. Zero to Three's alternative nosol-
ogy has been recently updated as DC:0-3-R
(Zero to Three, 2005), and is in use in many
parts of the world. In addition, the Research
Diagnostic Criteria for Infants and Pre-
schoolers (American Academy of Child and
Adolescent Psychiatry, 2003) was developed
by clinical investigators to enhance unifor-
mity in research efforts. Finally, the DSM-
V, scheduled for publication in 2012, has
an explicit goal of incorporating a develop-
mental focus, including age-related subtypes
of disorders where the evidence warrants it
(Pine et al., 2008). This level of activity un-
derscores considerable interest in psychiatric
disorders in young children.
We believe that at this early stage of the
science of infant mental health, both the
risk and protective factor approach of de-
velopmental psychopathology and the cat-
egorical disorder approach of many clinical
studies have merit and are worthy of further
investigation. Each approach, in fact, may
complement the other. In addition, we must
concern ourselves not only with adverse out-
comes but also with desired outcomes and
how to achieve them. This point leads to a
discussion of how best to promote healthy
outcomes in infant mental health.
Social Competence and Resilience
Health is sometimes defined as the absence
of disease, although increasingly research-
ers and clinicians are concerned with health
promotion, that is, in enhancing individuals
quality of experience. One aspect of "qual-
ity of experience" is social competence, the
ability to adapt successfully to differing
social and environmental demands. Social
competence, of course, is an ongoing adap-
tive capacity that itself may change over time
in relation to different stressors and situa-
tions. A focus on competence also reminds
us that symptoms alone do not make a dis-
order; their functional significance for the
individual also must be considered. Social
competence has emerged as an increasingly
important outcome in infant mental health,
as well as in studies of developmental psy-
chopathology.
A special form of social competence re-
ceiving increasing attention is resilience.
Resilience is demonstrated by infants and
young children who achieve positive out-
comes despite high-risk status, who main-
tain competent functioning despite stressful
life circumstances, and who recover from
traumatic events and experiences (Masten
& Coatesworth, 1998). Increasingly, it has
become clear that resilience, like compe-
tence, is a multidimensional construct, and
one that changes over time and context. In
addition, it may be that rather than being re-
silient to many problems, individuals may be
resilient to some stressors but not to others
(Rutter, 2000).
For children in the early years, having a
relationship with a caregiver who is available
and responsive to their needs, able to help
them navigate the demands of development
over time, is likely to be the most important
factor in helping them to achieve positive
outcomes, maintain competent functioning
under stress, and recover from traumatic ex-
periences. Young children who have the ca-
pacity to elicit support and positive responses
from others may be at an advantage in this
regard (Werner & Smith, 2001). Enforcing
policies that support families-especially
those that have limited resources-from the
time they are expecting through their child's
early years is the best way to enhance young
children's competent functioning (Center on
the Developing Child at Harvard University,
2007).
Some Early Problems Are Enduring
As noted above, not all problem behaviors
seen in the early years are transient. We turn
next to consider examples of enduring quali-
ties of at least some forms of psychopathol-
ogy and consider the implication of these
findings. We consider first the subsyndromal
risk factor of aggression and then consider
the categorical diagnosis of posttraumatic
stress disorder.
Aggression
Aggression, defiance, and temper tantrums
typically peak in early toddlerhood and de-
crease by school entry; however, some chil-
dren do not show this normative decline. In
the National Institute of Child Health and
Human Development (NICHD) study of
child care, investigators identified a cluster
of children who exhibited very high levels of
aggression at age 2 years and again at age
9 years (National Institute of Child Health
 1. The Scope of Infant Mental Health
and Human Development Early Child Care
Research Network, 2004). Family correlates
of children with stable high levels of aggres-
sion included lower social class, less maternal
education, reduced sensitivity to the child,
harsh and punitive parenting, depressive
symptoms in the parent, and parents having
fewer child-centered attitudes. Similarly, in a
longitudinal study of 318 children at ages 2,
4, and 5 a latent profile analysis resulted in
two distinct longitudinal profiles of disrup-
tive behavior (Degnan, Calkins, Keane, &
Hill-Soderlund, 2008). One high-aggression
profile was characterized by high child re-
activity (children who reacted strongly and
quickly to frustration) combined with highly
controlling maternal behavior. Another was
characterized by low child regulation (poor
efforts to regulate emotions) combined with
low levels of maternal control. In both of
these studies, aggression is stable over time
and associated with stable parental charac-
teristics.
Aggression in young children is not with-
out consequences. Gilliam (2005) deter-
mined that state-run pre-K programs have
three times the rate of expulsion of grades
K-12. The reason young children get ex-
pelled from child care centers and pre-K is
almost always aggression. Longer-term con-
sequences are also important, as aggressive
school-age children may begin a path toward
antisocial behavior in adolescence or adult-
hood (Frick & Marsee, 2006).
Posttraumatic Stress Disorder
It is well known that many adults and older
children who have been severely trauma-
tized develop posttraumatic stress disorder
(PTSD), showing signs of hyperarousal, re-
experiencing the trauma, avoiding remind-
ers of the trauma, and/or numbing of re-
sponsiveness. A series of studies of young
children has demonstrated that these same
symptoms are apparent in infants, toddlers,
and preschoolers, although their manifesta-
tions are different than in older children and
adults because of obvious developmental dif-
ferences (see Scheeringa, Chapter 21, this vol-
ume). In addition, two studies that have
followed the course of traumatized young
children indicate that signs and symptoms
exhibited following a traumatic event are
not transient. Scheeringa, Zeanah, Myers,
and Putnam (2005) studied 62 children with
13
mixed traumatic experiences 4 months, 16
months, and 28 months after the trauma.
They found significant stability of symptoms
over the 2 years, with almost no diminish-
ment of symptoms. Meiser-Stedman, Smith,
Glucksman, Yule, and Dalgleish (2008)
studied 62 preschool children 2-4 weeks
and 6 months after they had experienced
motor vehicle accidents. They found that the
diagnosis of PTSD was moderately stable
over the 6-month interval, even though the
initial assessment occurred before a month
had passed from the accident.
Treatment studies of PTSD that include
control groups also indicate a similar persis-
tence of symptoms over time. For example,
Lieberman, Van Horn, and Ippen (2005)
studied the effectiveness of child-parent psy-
chotherapy as a treatment of PTSD in young
children exposed to partner violence. The
comparison condition was case manage-
ment, involving monthly telephone contact
with the mothers as well as providing infor-
mation about and referrals to, local mental
health clinics. Immediately after treatment
(1 year after the trauma), the group who re-
ceived child-parent psychotherapy showed
statistically significant improvements in
child posttraumatic stress symptoms, but the
group receiving case management showed no
significant diminishment of signs of PTSD.
These results show that young children re-
ceiving case management and sometimes
referral experienced stability in their symp-
toms over 12 months.
Implications
These findings are selective rather than
comprehensive, but they illustrate that it is
no longer acceptable to assume that early-
a ppearing symptomatology is always, or
even usually, transient. Furthermore, there
are reasons to believe that intervening earlier
is more effective-at least for some domains
of development.
Dishian and colleagues (2008) suggest
three reasons why earlier intervention may
be more beneficial. First, earlier interven-
tions may target child behaviors before they
take on a more serious form. In their focus
on externalizing problems, they argue that
noncompliant and oppositional behaviors
are easier to remediate than are lying, steal-
ing, and proactive aggression. Second, if
children are younger, then parents are also
14 I. DEVELOPMENT AND CONTEXT
younger and may have had fewer stressful
experiences and more capacity to change.
Third, the sense of optimism caregivers have
regarding the possibility of parent-child
relationship change is much higher during
their offspring's early childhood.
Knudsen and colleagues (Knudsen, Heck-
man, Cameron, & Shonkoff, 2006) pointed
out that there is a convergence of findings
from child development, neuroscience, and
economic research indicating that greater re-
turn on investments are to be expected when
intervening earlier. Citing studies from all
three areas of research, they present compel-
ling evidence that early intervention is more
likely to be effective, providing a basis for
policies that support a broad array of early
childhood initiatives (see Knitzer & Lefkow-
itz, 2006). This point leads us to consider
the kinds of early intervention that infant
mental health recommends.
COMPREHENSIVE
INTERVENTIONS ARE NEEDED
The goals of the infant mental health field
are to reduce or eliminate suffering, to pre-
vent adverse outcomes (school failure, delin-
quency, psychiatric morbidity, interpersonal
isolation or conflicts, developmental delays
and deviance), and to promote healthy out-
comes by enhancing social competence and
resilience. In order to accomplish these
overarching goals, interventions must (1)
enhance the ability of caregivers to nurture
FIGURE 1.1. Continuum of services at state and local levels.
young children effectively, (2) ensure that
families in need of additional services can
obtain them, and (3) increase the ability of
nonfamilial caregivers to identify, address,
and prevent social-emotional problems in
early childhood. The targets of intervention
can be the child's behavior, the parent's be-
havior, or even the social context in which
the child is developing, but the main focus of
infant mental health is on strengthening or
improving relationships as they impact the
young child's development and behavior.
In Figure 1.1, we present a model of in-
fant mental health services, based on a pre-
ventive health perspective (Mrazek & Hag-
gerty, 1994; National Research Council and
Institute of Medicine, 2000) that represents
an update of a previous conceptualization
(Zeanah, Stafford, Nagle, et al., 2005).
Mrazek and Haggerty (1994) distinguished
between prevention and treatment services.
Preventive interventions aim to prevent the
initial onset of a disorder, decrease causal
factors and increase protective factors, and/
or decrease the severity or duration of a dis-
order. Specifically, preventive interventions
emphasize altering infant and parent behav-
iors and family functioning in order to pre-
serve or restore infants to more normative
developmental trajectories. For example,
intrinsic infant risk factors such as difficult
temperament cannot be prevented, but the
adverse consequences of difficult tempera-
ment, such as the emergence of behavior
problems, can be a focus of prevention ef-
forts.
 1. The Scope of Infant Mental Health
Mrazek and Haggerty (1994) divided
preventive interventions into three distinct
levels. Universal preventions are considered
desirable for everyone in an eligible popu-
lation; professional assistance may or may
not be needed. Selective preventions target
members of a group who have high lifetime
or high imminent risk for subsequent prob-
lems. Finally, indicated preventions target
those who manifest minimal but detectable
behavioral symptoms that may later become
a full-blown disorder. Treatment of existing
disorders adds a fourth level to this concep-
tualization (see Figure 1.1).
Since infants and young children grow and
develop within multiple contexts, biologi-
cal, social, and relationship issues are often
interrelated, and a continuum of services is
needed. Infants and families may seek ser-
vices at any point along the continuum or
more than one point simultaneously. For
example, a young child who requires treat-
ment for trauma symptoms related to abuse
or neglect may also need preventive health
care; access to services for basic needs such
- as food, shelter, or clothing; or specialized
developmental services such as speech and
language or physical therapy. A child being
seen for a well-child visit may be identified
as having behavioral problems that warrant
more intensive or specialized interventions.
Thus, cross-discipline and often cross-
system collaboration is essential. In fact, in
the United States, major policy initiatives
in infant mental health are evident in most
states, supported by federal and/or state gov-
ernments (Rosenthal & Kaye, 2005).
Universal Prevention
Some services are believed to be important
for all infants and families, either for pre-
vention or for health promotion purposes.
These universal services seek to avert or
prevent the onset of problems and/or seek to
enhance social-emotional health arid devel-
opment. In infant mental health, approaches
include education regarding normal infant
health and development, increasing knowl-
edge about what constitutes healthy parent-
infant relationships, and access or referral
to additional services as needed. Although
most universal services are aimed at indi-
viduals or families, in some cases, a commu-
nity approach is needed to ensure that basic
15
needs such as safe housing, appropriate nu-
trition, and availability of health and human
services are met even before other issues can
be addressed.
Early child care provides one example of a
universal setting for addressing infant men-
tal health. Scarr (1998) declared that there is
an international consensus about what con-
stitutes quality child care-namely, warm,
supportive interactions with adults in a safe,
healthy, and stimulating environment. Con-
siderable evidence supports her assertion.
For example, the NICHD study of early
child care is a prospective, longitudinal study
designed to examine concurrent, long-term,
and cumulative influences of variations in
early child care experiences of young chil-
dren. In this study, 1,364 healthy full-term
newborns were recruited in 10 sites around
the United States. Investigators examined
what aspects of child care were important
for promoting child development across a
number of domains by assessing the child,
the family, and the child care setting longi-
tudinally; among child care variables, qual-
ity of care was the most important predictor
of child outcomes. Quality of care is related
to cognitive and language outcomes, as well
as social and behavioral outcomes, in young
children (National Institute of Child Health
and Human Development Early Child Care
Research Network, 2005). In other words,
access to quality child care is a vitally im-
portant intervention for young children and
should be the focus of sustained policy ef-
forts to help achieve that goal.
An important caveat was that character-
istics of the parent-child relationship were
better predictor of child outcomes than any
combination of child care variables (Nation-
al Institute of Child Health and Human De-
velopment Early Child Care Research Net-
work, 2006). This does not mean that child
care experiences are unimportant. Rather, it
emphasizeS' the importance of all care giving
relationships for young children, with spe-
cial primacy for parent-child relationships.
Selective Approaches to Intervention
Some interventions are provided to families
of young children who have been selected
because they are "at risk" for poorer so-
cial and emotional outcomes. Some within
the group may be functioning well; others
16 I. DEVELOPMENT AND CONTEXT
may be more obviously struggling. Interven-
tions are presumably developed to address
the risks inherent in the population, and
typically, specific outcomes are monitored
or measured. Selective interventions may be
delivered in a variety of settings (e.g., health,
mental health, educational, or social servic-
es), and there is a great range in the structure
of such services, such as frequency or inten-
sity, type of intervention provided, skills or
behaviors that are targeted, and amount of
monitoring or follow-up.
A notable example of a selective preven-
tion directed at improving maternal and
infant outcomes, including the reduction of
abuse and neglect in a high-risk, impover-
ished sample, is the work of Olds, Salder,
and Kitzman (2007). They pioneered the
Nurse-Family Partnership (NFP), a nurse-
home visitation intervention for impover-
ished first-time mothers. The preventive in-
tervention begins prior to the 28th week of
pregnancy and continues through the child's
second birthday. Though the NFP program
uses attachment theory, social learning the-
ory, and human ecology theory to ground
the work, the program evolved out of a pub-
lic health rather than mental health delivery
approach.
NFP has three major goals: to improve
pregnancy health outcomes, to improve in-
fant health and development outcomes, and
to improve maternal life course development.
Highly trained nurses use manualized guide-
lines to address issues related to personal
health and health, quality of caregiving for
the infant, maternal life course develop-
ment, and social support. Special attention
is given to the importance of establishing a
trusting, consistent relationship between the
nurse and the client, and the development
of a safe, nurturing, and enriched parent-
infant relationship.
Through a series of randomized controlled
trials, NFP has demonstrated significant im-
pact across a variety of maternal and infant
health and social outcomes, including reduc-
tion in child maltreatment, reductions in se-
rious accidental injuries in children, delays
in subsequent pregnancies, and increased
maternal employment, as well as reductions
in child and maternal criminal and antisocial
behaviors as long as 15 years after program
completion (Olds et al., 2007). Importantly,
two independent groups have shown that the
program has yielded significant cost-benefit
advantages (Aos, Lieb, Mayfield, Miller, &
Pennucci, 2004; Karoly, Kilburn, & Can-
non, 2005).
Indicated Approaches
to Preventive Intervention
When subsyndromal problems are already
evident in young children, indicated inter-
ventions may be applied. These interventions
are aimed at preventing early manifestations
of deviance from becoming clinical disorders
in later development.
Insecure and especially disorganized at-
tachments between young children and
their caregivers are known to be a risk fac-
tor for subsequent psychosocial adaptation.
Because sensitive and responsive parenting
is associated with secure attachment, van
den Boom (1994) developed an intervention
designed to enhance secure attachment in
infants believed to be at risk because of tem-
peramental irritability. She delivered three
home visits to low-income mothers and their
6- to 9-month-old temperamentally irritable
infants. The intervention focused on increas-
ing mothers' sensitive responsiveness to their
infants' cues. Findings from a randomized
trial of 100 infant-mother pairs demon-
strated that when infants were 9 months old,
program mothers were significantly more re-
sponsive, stimulating, and visually attentive.
At 12 and 18 months old, children whose
mothers receiveq the intervention were sig-
nificantly more likely to be securely attached
than control children (van den Boom, 1994,
1995). These findings led Juffer, Bakermans-
Kranenburg, and van IJzendoorn (2007) to
develop and evaluate a promising interven-
tion called the Video-based Intervention to
Promote Positive Parenting. This interven-
tion is targeted to dyads at risk for the ad-
verse consequences of insecure attachment
and has been shown to reduce externalizing
problems in young children.
Treatment of Established Disorders
For young children who already have iden-
tifiable disorders, psychotherapeutic services
aimed at alleviating suffering or repairing
or remediating functioning are necessary.
Most often these services are provided by
mental health professionals trained in spe-
 1. The Scope of Infant Mental Health
cific infant mental health assessment and in-
tervention techniques. Treatment of already
identified problems may be focused primar-
ily on changing the infant (Benoit, Wang, &
Zlotki, 2001), the parent and his or her be-
havior (McDonough, 2000), or the infant-
parent relationship (Lieberman, Silverman,
& Pawl, 2000). Stern (1995) has argued that
these different forms of intervention may
use different strategies and different ports of
entry into the infant-parent dyad, but all are
concerned with changing the relationship as
a way of changing infant behavior and ex-
perience.
Treatment of established problems is con-
cerned with current resolution of symptoms
and distress but also with infants' develop-
mental trajectories. For these reasons, infant
mental health treatment is concerned simul-
taneously with present and future adapta-
tion of the child.
An increasing number of treatments in in-
fant mental health are supported empirical-
ly. Perhaps the best studied is child-parent
psychotherapy. Originally pioneered by Frai-
berg and colleagues (Fraiberg et al., 1975),
this treatment is a manualized interven-
tion used primarily with high-risk families
that have children less than 5 years of age.
Child-parent psychotherapy tries to estab-
lish links between the parents' early child-
hood experiences and their current feelings,
perceptions, and behaviors toward their in-
fants and young children. The therapist acts
as a translator of the emotional experience
of parent and child, attending carefully to
the parent's stressful life circumstances and
culturally derived values.
A new generation of clinician research-
ers has more fully developed child-parent
psychotherapy, expanded its application to
preschool-age children, and systematically
studied its effectiveness (see Lieberman &
Van Horn, Chapter 27, this volume); in fact,
there are now five randomized controlled tri-
als supporting its efficacy. Child-parent psy-
chotherapy has been shown to be effective at
(1) reducing insecure attachment behaviors
in toddlers of stressed immigrant families
(Lieberman, Weston, & Pawl, 1991), (2) re-
ducing signs of PTSD in children traumatized
by marital violence (Lieberman et al., 2005;
Lieberman, Ippen, & Van Horn, 2006), and
(3) increasing secure attachments in infants
of depressed mothers (Cicchetti, Toth, &
17
Rogosh, 1999; Toth, Rogosch, Manly, &
Cicchetti, 2006) and in maltreated young
children (Cicchetti, Rogosch, & Toth, 2006;
Toth, Maughan, Manly, Spagnola, & Cic-
chetti, 2002).
Challenges of Infant Mental
Health Interventions
Preventive interventions and treatment ef-
forts in infant mental health share several
challenges. First, it is important to involve
families of young children and to listen and
incorporate their concerns into the planning
and implementation of interventions. This
requires the development of a working alli-
ance between parents and intervener-that
is, a shared commitment to work together
in the best interest of the child. The relation-
ship between the parent and the intervener
often becomes a model for the respectful
and empathic way parents learn to relate to
their infant.
Second, practitioners must recognize that
personal, familial, ethnic, cultural, profes-
sional, and organizational values impact
every aspect of interventions. These values
create explicit and implicit lenses through
which relationships are understood. Often,
the situations faced by infants and young
children evoke strong feelings in the pro-
fessional. Recognizing and understanding
one's own value system as well as how pro-
fessional perspectives impact one's ability to
understand the dyad are an ongoing chal-
lenge. Countertransference, including prob-
lems with boundaries, value judgments, and
rescue fantasies, can cloud objectivity and
undermine the potential for the intervention
to succeed. Adequate provider training and
supervision are viewed as essential precur-
sors to developing effective interventions
(see Hinshaw-Fuselier, Zeanah, & Larrieu,
Chapter 33, this volume).
A third related challenge, particularly for
professionals who have been taught to focus
on individuals, is keeping the focus on the
infant-parent relationship. The professional
must pay attention not only to the behavioral
interactions within the dyad, but also must
appreciate the parent's emotional experience
of the young child, and the young child's ex-
perience of the parent. Recognition of each
of these perspectives requires a paradigm
shift for most early childhood professionals,
 18 I. DEVELOPMENT AND CONTEXT
and it requires significant training in order
to fully understand and to integrate these
perspectives into clinical work.
Finally, though the evidence base in infant
mental health is growing, ongoing research
into preventive interventions and treatments
is needed. It is important to identify the
components of the intervention, such as (1)
the targeted recipient; (2) methods of inter-
vention; (3) frequency, intensity, and length
of services; (4) location of service delivery;
and (5) type of service provider. Then it is
important to link these components with
anticipated, measurable outcomes (Karoly
et al., 2005). Explicating these components
and applying sound research methodology
will enhance the evidence base and even-
tually will allow us in the field to identify
critical elements and combination strate-
gies that make a difference within and pos-
sibly across programs. For example, Olds
and colleagues (2002) showed that nurses
outperformed paraprofessionals in terms of
outcomes achieved, keeping other character-
istics of the NFP model constant. This find-
ing helps justify the extra cost of using nurs-
es to deliver services in this intervention.
There is a particular need for research
that focuses on the impact of sequential pre-
ventive interventions (Mrazek & Haggerty,
1994). This area has hardly been studied at
all, no doubt partly because it poses signifi-
cant fiscal and logistical challenges.
In developing more refined questions in in-
tervention research, clinicians need to work
closely with researchers. Ideally, the latest
research findings inform clinical practice,
and clinical practice informs research de-
signs by introducing promising approaches.
The ultimate goal is for clinicians to be able
to select an intervention that is best suited to
address an individual child's particular prob-
lems and circumstances. Policies ensuring
that families have access to individualized
services will become increasingly important
as our ability to match children and families
with specific interventions improves.
CONCLUSIONS
The field of infant mental health emphasizes
the importance of caregiving relationships
as having major effects on the young child's
social and emotional experience. Healthy
j I
caregiving relationships, which are embed-
ded within multiple social and cultural con-
texts, promote social competence in young
children, and social competence is associ-
ated with adaptive behavioral, emotional,
and cognitive outcomes. The scope of infant
mental health includes clinical, research, and
policy efforts and encompasses the theoreti-
cal perspectives and knowledge base of mul-
tiple professional disciplines. The complex-
ity of the problems of infants and toddlers
must be matched by the comprehensiveness
of our efforts to minimize their suffering
and enhance their competence.
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